Reviews and Overviews

A Meta-Analysis of Cognitive Remediation in Schizophrenia

Susan R. McGurk, Ph.D.
Elizabeth W. Twamley, Ph.D.
David I. Sitzer, Ph.D.
Gregory J. McHugo, Ph.D.
Kim T. Mueser, Ph.D.
Objective: This study evaluated the ef-
fects of cognitive remediation for improving
cognitive performance, symptoms, and
psychosocial functioning in schizophrenia.
Method: A meta-analysis was conducted
of 26 randomized, controlled trials of cog-
nitive remediation in schizophrenia in-
cluding 1,151 patients.
Results: Cognitive remediation was asso-
ciated with significant improvements
across all three outcomes, with a medium
effect size for cognitive performance
(0.41), a slightly lower effect size for psy-
chosocial functioning (0.36), and a small
effect size for symptoms (0.28). The ef-
fects of cognitive remediation on psycho-
social functioning were significantly stron-
ger in studies that provided adjunctive
psychiatric rehabilitation than in those
that provided cognitive remediation
alone.
Conclusions: Cognitive remediation pro-
duces moderate improvements in cogni-
tive performance and, when combined
with psychiatric rehabilitation, also im-
proves functional outcomes.

(Am J Psychiatry 2007; 164:1791–1802)

C ognitive impairment is a core feature of schizophre-

nia, with converging evidence showing that it is strongly
related to functioning in areas such as work, social rela-
tionships, and independent living (1, 2). Furthermore,
cognitive functioning is a robust predictor of response to
psychiatric rehabilitation (i.e., systematic efforts to im-
prove the psychosocial functioning of persons with severe
mental illness) (3), including outcomes such as work, so-
cial skills, and self-care (1, 4, 5). Because of the importance
of cognitive impairment in schizophrenia, it has been
identified as an appropriate target for interventions (6).
Currently available pharmacological treatments have
limited effects on cognition in schizophrenia (7, 8) and
even less impact on community functioning (9). To address
the problem of cognitive impairment in schizophrenia, a
range of cognitive remediation programs has been devel-
oped and evaluated over the past 40 years. These programs
employ a variety of methods, such as drill and practice ex-
ercises, teaching strategies to improve cognitive function-
ing, compensatory strategies to reduce the effects of per-
sistent cognitive impairments, and group discussions.
Several reviews of research on cognitive rehabilitation in
schizophrenia have been published (10–13). The general
conclusions from these reviews have been that cognitive
remediation leads to modest improvements in perfor-
mance on neuropsychological tests but has no impact on
functional outcomes. However, these reviews were limited
by the relatively small number of studies that actually mea-
sured psychosocial functioning, precluding any definitive
conclusions about the effects of cognitive remediation on
psychosocial adjustment or the identification of program
characteristics that may contribute to such effects. The ra-
tionale for cognitive remediation is chiefly predicated on
its presumed effects on psychosocial functioning and im-
proved response to rehabilitation. Therefore, a critical ex-
amination of the effects of cognitive remediation on func-
tional outcomes is necessary in order to determine its
potential role in the treatment of schizophrenia.
In recent years, the number of studies that examined
psychosocial functioning has grown sufficiently to permit
a closer look at the impact of cognitive remediation. We
conducted a meta-analysis of controlled studies to evalu-
ate the effects of cognitive remediation on cognitive func-
tioning, symptoms, and functional outcomes. We also ex-
amined whether characteristics of cognitive remediation
programs (e.g., hours of cognitive training), the provision
of adjunctive psychiatric rehabilitation, treatment set-
tings, patient demographics, or type of control group was
related to improved outcomes. We hypothesized that cog-
nitive remediation would improve both cognitive func-
tioning and psychosocial adjustment. We also hypothe-
sized that programs that provided more hours of cognitive
training would have stronger effects on cognitive func-
tioning and that adjunctive psychiatric rehabilitation
would be associated with greater improvements in func-
tional outcomes.
Method
Studies for the meta-analysis were identified by conducting
MEDLINE and PsycINFO searches for English language articles
published in peer-reviewed journals. The following search terms
were used: cognitive training, cognitive remediation, cognitive re-
habilitation, and schizophrenia. Studies meeting the following cri-
teria were included: 1) a randomized, controlled trial of a psycho-
social intervention designed to improve cognitive functioning; 2)
an assessment of performance with at least one neuropsychologi-
cal measure that had the potential to reflect generalization of ef-

Am J Psychiatry 164:12, December 2007 ajp.psychiatryonline.org 1791

COGNITIVE REMEDIATION IN SCHIZOPHRENIA

TABLE 1. Neuropsychological Assessments Included in Each Cognitive Domain

Domain Assessment
Attention/vigilance Wechsler Memory Scale (WMS) information and mental control subtests
Search-a-Word
Cancellation tasks
Continuous Performance Tests
Span of apprehension
Labyrinth Test
Sustained Attention Test
Span: hits, time, and overall
Preattentional processing
Cross-over reaction time
Cross-modal reaction time
Embedded Figures Test
COGLAB apprehension/masking
Dichotic listening tasks
Speed of processing Trail Making Test, Parts A and B
WAIS, WAIS-R, or WAIS-III digit symbol subtest
Stroop Test, color and word conditions
Reaction time tests
Letters and category fluency
Verbal working memory WAIS, WAIS-R, WAIS-III, or WMS digit span
WAIS-III letter-number sequencing and arithmetic subtests
Digit Span Distractibility Test
Other digit span tasks
Trained Word Recall Task
Other arithmetic tasks
Sentence span
Dual span
Paced Auditory Serial Addition Test
Nonverbal working memory Wechsler Memory Scale—Revised (WMS-R) visual span
Dual span
Verbal learning and memory WMS, WMS-R, or WMS-III logical memory and verbal paired associates subtests
California Verbal Learning Test
Rey Auditory Verbal Learning Test
Hopkins Verbal Learning Test
Word List Recall Task
Verbal learning paradigm
Denman Neuropsychological Memory Test
Span-Completeness Verbal Learning Test
Visual learning and memory WMS, WMS-R, or WMS-III visual recall, visual reproduction, faces, and figural memory subtests
Memory for Designs Test
Rey-Osterrieth Complex Figure Test
Kimura recurring figures
Denman Neuropsychological Memory Test
Reasoning and problem solving WAIS, WAIS-R, or WAIS-III similarities and picture arrangement subtests
Wechsler Intelligence Scale for Children mazes subtest
Stroop Test interference condition
Independent Living Scale—problem solving
Gorham’s Proverbs Test and other proverb interpretation tasks
Wisconsin Card Sorting Test
Trail Making Test (B – A)
Hinting Task
Labyrinth Test
Tower of Hanoi
Tower of London
Response inhibition
Six elements
Categories
COGLAB card sorting test
Social cognition Social perception (Emotion Matching Test and Emotion Labeling Test)
Bell-Lysaker Emotion Recognition Test
Social cognition
Other cognitive
Cognitive measures of multiple domains Global cognitive scores
Mini-Mental State Examination
Cognitive measures not considered sensi-
tive to change Peabody Picture Vocabulary Test
Shipley Institute of Living Scale IQ estimate
WAIS-R comprehension subtest
Verbal IQ
Cognitive measures lacking consensus Cognitive style
Hayling Sentence Completion Task
(continued)

1792 ajp.psychiatryonline.org Am J Psychiatry 164:12, December 2007

 McGURK, TWAMLEY, SITZER, ET AL.

TABLE 1. Neuropsychological Assessments Included in Each Cognitive Domain (continued)

Purdue Pegboard
Tactile performance
WMS orientation subtest
Symptoms Scale for the Assessment of Positive Symptoms
Scale for the Assessment of Negative Symptoms
Positive and Negative Syndrome Scale
Brief Psychiatric Rating Scale
Holtzman Inkblot Test
Paranoid Depression Scale
Present State Exam
Thought, language, and communication
Functioning Bay Area Functional Performance Evaluation
Percent “sick talk”/incoherence during the interview
Life skills profile
Global Assessment Scale
Nurses’ Observation Scale for Inpatient Evaluation
Disability Assessment Schedule
Employment
Social Behaviour Schedule
Micro-Module Learning Test
Assessment of Interpersonal Problem-Solving Skills
Social adjustment

fects rather than assessments on trained tasks only; 3) data avail-
able on either group means and standard deviations for baseline
and postintervention cognitive tests or statistics from which effect
sizes could be calculated; 4) a minimum of 75% of the sample re-
ported to have schizophrenia, schizoaffective disorder, or schizo-
phreniform disorder.
Categorization of Neuropsychological Tests
Neuropsychological tests were grouped into the following cog-
nitive domains described by the Measurement and Treatment Re-
search to Improve Cognition in Schizophrenia (MATRICS) con-
sensus panel (6): attention/vigilance, speed of processing, verbal
working memory, nonverbal working memory, verbal learning
and memory, visual learning and memory, reasoning/problem
solving, and social cognition. Each of the neuropsychological
measures used in the studies meeting the inclusion criteria was
assigned to one cognitive domain by consensus of the first three
authors. Measures for which no consensus could be reached, that
were judged to reflect more than one cognitive domain, or that
the MATRICS panel deemed not sensitive to change were not in-
cluded in the meta-analysis. Table 1 summarizes which neuro-
psychological tests were included in each cognitive domain.
Calculation of Effect Sizes
Effect sizes were calculated by using posttreatment group
means and standard deviations (14), pre-post difference scores,
or analysis of covariance (ANCOVA) or multivariate analysis of co-
variance (MANCOVA) F values that covaried baseline scores on
the dependent measures. Effect sizes can generally be catego-
rized as small (0.2), medium (0.5), or large (0.8) (15). When a study
reported data from multiple measures classified in the same cog-
nitive domain, the mean of the effect sizes from those measures
was used. Effect size distributions were evaluated for outliers, re-
sulting in exclusion of results of one study from the functional
outcome analyses (16).
Meta-Analytic Procedure
Meta-analyses were conducted with BioStat software (17). In
order to control for study differences in sample size when mean
effect sizes were computed, studies were weighted according to
their inverse variance estimates. To determine whether mean ef-
fect sizes were statistically significant, the confidence interval (CI)
and z transformation of the effect size were used. The homogene-
ity of the effect sizes across studies for each outcome domain was
evaluated by computing the Q statistic (18). Then the significance
level of the mean effect sizes was computed by conducting fixed-
effects linear models except when the Q statistic indicated signif-
icant within-group heterogeneity, in which case we used random
effects models. Moderator analyses were then conducted on
those domains with significant heterogeneity, based on the Q sta-
tistic, to determine whether any participant, setting, or program
variables explained variations between studies in effect sizes.
These analyses were performed by clustering studies into two
contrasting groups based on the moderator variable and comput-
ing the Q between and Q within statistics (18).
Moderator Variables
Several variables were considered as potential moderators of
cognitive remediation. Each moderator variable was divided into
two levels based on a median split. The moderator variables and
levels were 1) participant characteristics: age (years) (15–37/38–
50), 2) the setting (inpatient/outpatient), 3) the type of control
group (active control [e.g., another intervention, such as cogni-
tive behavior therapy or motivational interviewing]/passive con-
trol [e.g., viewing educational videos or treatment as usual]), 4)
program characteristics: type of intervention (drill and practice/
drill and practice plus strategy coaching or strategy coaching
alone), hours of practice (determined for the overall program as
well as individual cognitive domains), and the provision of ad-
junctive psychiatric rehabilitation (no/yes).
Some programs that provided training in social cognition em-
ployed a combination of cognitive remediation and other rehabil-
itation approaches, such as social skills training (19, 20), whereas
others employed strictly cognitive remediation methods, such as
computer-based training tasks (21). The number of hours of social
cognition training was included in the total number of cognitive
remediation hours only for the programs that did not combine the
training with another rehabilitation approach. A variety of psychi-
atric rehabilitation approaches were provided in conjunction with
cognitive remediation, including social skills training (20, 22), so-
cial skills/social perception training (19, 23), supported employ-
ment (24), vocational rehabilitation (25), and vocational rehabili-
tation and social information processing groups (26).
Results
Data from 26 studies (1,151 subjects) were included.
The studies, characteristics of participants and programs,

Am J Psychiatry 164:12, December 2007 ajp.psychiatryonline.org 1793

COGNITIVE REMEDIATION IN SCHIZOPHRENIA

TABLE 2. Description of Randomized, Controlled Trials of Cognitive Remediation in Schizophrenia

Sample Characteristics—
Inpatient/Outpatient; Mean Age
(years); Mean Education (years);
Author % Male
Wagner (1968) (45), Inpatients; 44.8; not reported;
treatment 1 100%
Treatment group (N)
Noncomputerized attention
training (N=8)
Cognitive Remedia-
Drill and Practice/ tion Program In-
Drill and Strategy cluded Psychiatric
Coaching Rehabilitation
Drill and practice No

Wagner (1968) (45), Inpatients; 44.8; not reported; Noncomputerized abstraction Drill and practice No
treatment 2 100% training (N=8)

Wagner (1968) (45), Inpatients; 44.8; not reported; Noncomputerized attention and Drill and practice No
treatment 3 100% abstraction training (N=16)

Meichenbaum & Cameron Inpatients; 36.0; not reported; Noncomputerized training using Drill and practice No
(1973), includes 3-week 100% self-talk (N=5)
follow-up (16)

Benedict & Harris (1989) Inpatients; 30.3; not reported; Computerized training with Drill and practice No
(46) not reported advancement criteria (N=10)

Olbrich & Mussgay (1990) Inpatients; 30.7; 10.2; 57% Noncomputerized training (N=15) Drill and practice No
(43)

Hermanutz & Gestrich Inpatients; 31.0; 11.0; not Computerized attention training Drill and practice No
(1991) (42) reported (N=10)

Benedict et al. (1994) (47) Outpatients; 38.8; 11.0; 52% Computerized attention training Drill and practice No
(N=16)

Burda et al. (1994) (48) Inpatients; 46.6; 12.5; 97% Computerized training using Drill and practice No
Captain’s Log (N=40)

Field et al. (1997) (49) Outpatients; 28.6; not reported; Computerized training (N=5) Drill and practice No
90%

Medalia et al. (1998) (50) Inpatients; 32.5; 10.8; 78% Computerized attention training Drill and practice No
using orientation remedial mod-
ule (N=27)
Spaulding et al. (1999) (20) Inpatients; 35.7; 11.9; 63% Noncomputerized training using Drill and strategy Social skills training
integrated psychological therapy coaching groups
(N=49)

Wykes et al. (1999) (27); Outpatients; 38.5; 12.0; 76% Noncomputerized training with Drill and strategy No
Wykes et al. (2003) (30), errorless learning (N=17) coaching
6-month follow-up

Medalia et al. (2000) (51), Inpatients; 37.7; 11.5; 59% Computerized problem-solving Drill and strategy No
treatment 1 training (N=18) coaching
Medalia et al. (2000) (51), Inpatients; 36.5; 10.5; 59% Computerized memory training Drill and practice No
treatment 2 (N=18)

1794 ajp.psychiatryonline.org Am J Psychiatry 164:12, December 2007

 McGURK, TWAMLEY, SITZER, ET AL.

Hours/Weeks of Average Effect

Cognitive Remediation Cognitive Effect Size Average Effect Size Average Effect Size for
Control Group (active/ (excluding other (follow-up effect size in for Cognitive Size for Symptom Functioning
passive control, N) treatment) parentheses) Measures Measures Measures
Viewing treatment group 3 hours/1 week Visual learning memory= 1.10
stimuli without 0.80; reasoning and
responding (active problem solving=1.40
control, N=8)
Viewing treatment group 3 hours/1 week Visual learning memory= –0.04
stimuli without –1.21; reasoning and
responding (active problem solving=1.12
control, N=8)
Viewing treatment group 3 hours/1 week Visual learning memory= 0.32
stimuli without –0.09; reasoning and
responding (active problem solving=0.55
control, N=8)
Task practice without self- 4.1 hours/3 weeks Verbal working memory= 1.02 (1.65) 1.89 (2.08) 3.50 (3.99)
talk (active control, N=5) 0.77 (1.31); reasoning
and problem solving=
1.26 (1.99)
1. Computerized training 12.5 hours/8–14 Speed of processing=1.57 1.57
without advancement weeks
criteria (active control,
N=10); 2. Treatment as
usual (passive control,
N=10)
Arts and crafts groups 12 hours/3 weeks Attention/vigilance=0.52; 0.40 0.00
(active control, N=15) Verbal working mem-
ory=0.43; reasoning and
problem solving=0.26
1. Integrated psychologi- 7.5 hours/3–4 weeks Treatment versus active Treatment versus ac- Treatment versus Treatment
cal therapy focusing on control: attention/vigi- tive control=0.18; active control= versus active
cognitive, communica- lance=0.18; treatment treatment versus 0.43; treatment control=–0.47;
tion, and social training versus passive control: passive control= versus passive treatment
(active control, N=10); attention/vigilance= –0.09 control=0.24 versus passive
2. Treatment as usual –0.09 control=–0.46
(passive control, N=10)
Treatment as usual 12.5 hours/3–5 weeks Attention/vigilance=0.41; 0.27
(passive control, N=17) verbal learning and
memory=0.13
Treatment as usual 12 hours/8 weeks Speed of processing=0.58; 0.51
(passive control, N=29) attention/vigilance=
0.65; verbal working
memory=0.89; verbal
learning and memory=
0.69; visual learning
memory=–0.26
Graphics-based computer 6 hours/3 weeks Speed of processing=0.74; 0.79
games (active control, attention/vigilance=
N=5) 1.08; reasoning and
problem solving=0.54;
other=0.00
Watching National Geo- 6 hours/6 weeks Attention/vigilance=0.19 0.19 0.24
graphic documentaries
(passive control, N=27)
Group supportive therapy 68.3 hours/26 weeks Speed of processing=0.02; 0.08 0.55 0.53
emphasizing social skills attention/vigilance=
(active control, N=42) 0.38; verbal learning
and memory=–0.06;
visual learning memory=
–0.06; reasoning and
problem solving=0.14
Intensive occupational 24–40 hours/8–10 Speed of processing=0.26; 0.20 (0.20) 0.59 0.05
therapy (active control, weeks verbal working mem-
N=16) ory=0.27 (0.07); nonver-
bal working memory=
0.06; reasoning and
problem solving=0.20
(0.33)
Treatment as usual 4.2 hours/5 weeks Verbal learning and –0.43
(passive control, N=18) memory=–0.43
Treatment as usual 4.2 hours/5 weeks Verbal learning and –0.39
(passive control, N=18) memory=0.39 (continued)

Am J Psychiatry 164:12, December 2007 ajp.psychiatryonline.org 1795

COGNITIVE REMEDIATION IN SCHIZOPHRENIA

TABLE 2. Description of Randomized, Controlled Trials of Cognitive Remediation in Schizophrenia (continued)

Sample Characteristics—
Inpatient/Outpatient; Mean Age
(years); Mean Education (years);
Author % Male
Bell et al. (2001) (26) Outpatients in work therapy;
43.6; 13.2; 78%
Cognitive Remedia-
Drill and Practice/ tion Program In-
Drill and Strategy cluded Psychiatric
Treatment group (N) Coaching Rehabilitation
Computerized training using Drill and practice Vocational rehabilita-
CogReHab plus weekly social tion and social
information processing group information
(N=31) processing groups

Bell et al. (2003) (52), Same as above (N=47)

includes follow-up
Fiszdon et al. (2004) (53), Same as above (N=45)
includes follow-up
Fiszdon et al. (2005) (54) Same as above (N=57)

Van der Gaag (2002) (23) Inpatients; 31.1; not reported; Noncomputerized training (N=21) Drill and strategy Social skills/social
64% coaching perception training

Bellucci et al. (2002) (34) Outpatients; 42.0; 12.6; 47% Computerized training using Drill and practice No
Captain’s Log (N=17)

López-Luengo & Vázquez Outpatients; 33.5; not reported; Noncomputerized training using Drill and practice No
(2003) (55) 83% attention process training (N=13)

Hogarty et al. (2004) (19), Outpatients; 37.3; not reported; Computerized training using Drill and strategy Social skills/social
includes 12-month 59% orientation remedial module and coaching perception training
follow-up CogReHab plus group social groups
cognition exercises (N=67)

Ueland & Rund (2005) (21); Inpatients; 15.3; not reported; Computerized and non- Drill and strategy No
Ueland & Rund (2004) 50% computerized training (N=14) coaching
(44), 12-month follow-up

McGurk et al. (2005) (24) Outpatients in supported Computerized training using Drill and strategy Supported
employment; 37.5; 11.2; 55% Cogpack (N=23) coaching employment

Sartory et al. (2005) (56) Inpatients; 36.4; 10.3; 67% Computerized training using Drill and practice No
Cogpack (N=21)

Silverstein et al. (2005) (22) Inpatients; 39.3; 10.6; 87% Noncomputerized training using Drill and practice Social skills training
attention process training and groups
shaping (N=18)

Vauth et al. (2005) (25) Inpatients in vocational Computerized training using Drill and strategy Vocational
rehabilitation; 30.0; 12.5; 65% Cogpack and noncomputerized coaching rehabilitation
training, plus cognitive
adaptation therapy (N=47)

1796 ajp.psychiatryonline.org Am J Psychiatry 164:12, December 2007

 McGURK, TWAMLEY, SITZER, ET AL.

Hours/Weeks of Average Effect

Cognitive Remediation Cognitive Effect Size Average Effect Size Average Effect Size for
Control Group (active/ (excluding other (follow-up effect size in for Cognitive Size for Symptom Functioning
passive control, N) treatment) parentheses) Measures Measures Measures
Treatment as usual 36 hours/26 weeks Speed of processing=0.31; 0.50
(passive control, N=34) verbal working mem-
ory=0.30; reasoning and
problem solving=0.50;
social=0.90
Passive control, N=55 Verbal working memory= 0.40 (0.48)
0.40 (0.48)
Passive control, N=49 Verbal working memory= 0.53 (0.66)
0.53 (0.66)
Passive control, N=68 Verbal learning and mem- 0.36
ory=0.36
Leisure/games group 4 hours/11 weeks Speed of processing= 0.26
(active control, N=21) –0.02; attention/vigi-
lance=0.09; verbal
learning and memory=
0.41; visual learning
memory=0.47; reason-
ing and problem solv-
ing=0.09; social=0.51
Treatment as usual 8 hours/8 weeks Speed of processing=0.56; 0.52 0.32
(passive control, N=17) verbal working mem-
ory=0.52; verbal learn-
ing and memory=0.49
Treatment as usual 24 hours/43 weeks Speed of processing=0.32; 0.53
(passive control, N=11) attention vigilance=
0.54; verbal working
memory=0.48; verbal
learning and memory=
0.57; reasoning and
problem solving=0.45
Enriched supportive ther- 75 hours/104 weeks Speed of processing=0.83 0.60 (0.67) –0.07 (0.09) 0.37 (0.51)
apy including psychoed- (0.86); social=0.36 (0.66)
ucation, illness self-
management, and stress
management (active
control, N=54)
Treatment as usual 30 hours/12 weeks Attention/vigilance=0.31 0.37 (0.33) 0.25 (0.51) 0.31 (0.16)
(passive control, N=12) (0.28); verbal working
memory=0.54 (0.60);
verbal learning and
memory=0.33 (0.29);
visual learning mem-
ory=0.11 (0.17); reason-
ing and problem solv-
ing=0.57 (0.31)
Treatment as usual 24 hours/12 weeks Speed of processing=0.27; 0.33 0.45 1.76
(passive control, N=21) verbal working mem-
ory=0.42; verbal learn-
ing and memory=0.45;
reasoning and problem
solving=0.18
Treatment as usual 15 hours/3 weeks Speed of processing=0.69; 0.78
(passive control, N=21) verbal learning and
memory=0.88
Treatment as usual 18 hours/6 weeks Attention/vigilance=0.25; 0.37 0.41 0.68
(passive control, N=13) verbal working mem-
ory=0.38; verbal learn-
ing and memory=0.48
1. Vocational rehabilita- 24 hours/8 weeks Treatment versus active Treatment versus Treatment versus Treatment
tion and self-manage- control; attention/vigi- active control= active control= versus active
ment training for nega- lance=0.46; verbal 0.54; treatment 0.44; treatment control=0.10;
tive symptoms (active learning and memory= versus passive versus passive treatment
control, N=45); 2. Treat- 0.61; treatment versus control=0.54 control=0.19 versus passive
ment as usual (passive passive control; atten- control=0.46
control, N=46) tion/vigilance=0.46; ver-
bal learning and mem-
ory=0.55; reasoning and
problem solving=0.60 (continued)

Am J Psychiatry 164:12, December 2007 ajp.psychiatryonline.org 1797

COGNITIVE REMEDIATION IN SCHIZOPHRENIA

TABLE 2. Description of Randomized, Controlled Trials of Cognitive Remediation in Schizophrenia (continued)

Author
Penadés et al. (2006) (29),
includes 6-month follow-
up
Sample Characteristics—
Inpatient/Outpatient; Mean Age
(years); Mean Education (years);
% Male
Outpatients; 35.1; 10.2; 57%
Treatment group (N)
Noncomputerized training using
frontal/executive program with
errorless learning (N=20)
Cognitive Remedia-
Drill and Practice/ tion Program In-
Drill and Strategy cluded Psychiatric
Coaching Rehabilitation
Drill and practice No

and effect sizes are displayed in Table 2. The mean sample
size was 50 (SD=36, range=10–138). The mean age of the
participants was 36.3 years (SD=6.0, range of means=15–
47), the mean years of education was 11.8 (SD=1.0, range
of means=10–13), 69% of the participants were men, and
60% were inpatients. The mean duration of cognitive re-
mediation programs was 12.8 weeks (SD=20.9, range=1–
104). Programs targeted for training an average of 2.9 cog-
nitive domains (SD=1.6, range=1–6), whereas changes in
cognitive functioning were assessed on an average of 3.1
cognitive domains (SD=1.6, range=1–6). Sixty-nine per-
cent of the programs used a drill and practice interven-
tion; 23% provided adjunctive psychosocial rehabilitation.
Effects on Cognitive Performance
Only one study examined changes in nonverbal working
memory (27), so this domain was not included in the
meta-analysis. The effect sizes and related statistics for
overall cognition and the other seven individual cognitive
domains are provided in Table 3. In addition, the effect
sizes for overall cognitive functioning for each study are
depicted in Figure 1. The effect size for overall cognition
was significant, as well as for six of the seven domains of
cognitive performance. Most of the effects were in the me-
dium or low-medium effect size range, indicating im-
proved cognitive performance after cognitive remedia-
tion. The effect size for visual learning and memory was
not significant (0.09).
Six studies also reported cognitive data at follow-up (16,
19, 21, 28–30). For these studies, the average effect size at
posttreatment was 0.56 (t=4.8, df=5, p<0.001, CI=0.33–
0.79; Q=3.4, df=5, n.s.), and at follow-up, it was 0.66 (t=5.7,
df=5, p<0.001, CI=0.43–0.89; Q=7.8, df=5, n.s.). Similar to
the results at posttreatment, cognitive remediation was
associated with improved overall cognitive performance
an average of 8 months later.
Hedges’s Q was significant for only one cognitive do-
main, verbal learning and memory, indicating significant
heterogeneity in effect sizes to evaluate the effects of mod-
erators. For this domain, a larger effect size was associated
with more hours of cognitive remediation (0.57) com-
pared with fewer hours (0.29) (Q=3.7, df=1, p<0.05) and
with drill and practice (0.48) compared with drill and prac-
tice plus strategy coaching (0.23) (Q=2.0, df=1, p<0.05);
hours of cognitive remediation were unrelated to program
type (χ2=0.4, df=1, n.s.).
Effects on Symptoms and Functioning
Cognitive remediation was associated with a small ef-
fect size for symptoms (0.28) and between a small and a
medium effect size for functioning (0.35). There was sig-
nificant heterogeneity in the effect sizes for functioning
(Q=25.7, df=11, p<0.01), but not for symptoms. Moderator
analyses indicated that cognitive remediation resulted in
stronger effect sizes for improved psychosocial function-
ing in studies that provided adjunctive psychiatric rehabil-
itation (0.47) compared to no psychiatric rehabilitation
(0.05) (Q=5.5, df=1, p<0.01.), cognitive remediation pro-
grams that used drill and practice plus strategy coaching
(0.62) compared to drill and practice only (0.24) (Q=4.6,
df=1, p<0.05), and studies that included older (0.55) rather
than younger (0.18) patients (Q=5.7, df=1, p<0.05). Pro-
gram type was unrelated to age and to adjunctive psychi-
atric rehabilitation, but age and adjunctive psychiatric re-
habilitation were significantly associated (χ2=6.7, df=1,
p<0.05). Studies that provided psychiatric rehabilitation
tended to serve older patients.
Discussion
The results provide support for the effects of cognitive
remediation on improving cognitive functioning in
schizophrenia, with effect sizes in the medium range for
overall cognitive functioning (0.41) and six of the seven
cognitive domains (0.39–0.54). The effects of cognitive re-
mediation on cognitive performance were remarkably
similar across the 26 studies included in the analysis de-
spite differences in length and training methods between
cognitive remediation programs, inpatient/outpatient
setting, patient age, and provision of adjunctive psychiat-
ric rehabilitation. The results indicate that cognitive reme-
diation produced robust improvements in cognitive func-
tioning across a variety of program and patient conditions.
The effect sizes of cognitive remediation were homoge-
neously distributed across studies for overall cognitive
functioning and six of the seven cognitive domains, pre-
cluding the examination of moderators of treatment ef-
fects for most cognitive outcomes. Thus, contrary to our

1798 ajp.psychiatryonline.org Am J Psychiatry 164:12, December 2007

 McGURK, TWAMLEY, SITZER, ET AL.

Hours/Weeks of Average Effect

Cognitive Remediation Cognitive Effect Size Average Effect Size Average Effect Size for
Control Group (active/ (excluding other (follow-up effect size in for Cognitive Size for Symptom Functioning
passive control, N) treatment) parentheses) Measures Measures Measures
Cognitive behavioral ther- 40 hours/16 weeks Speed of processing=0.56 1.01 (1.42) –0.15 (–0.15) 0.42 (0.45)
apy for psychosis (active (1.02); verbal working
control, N=20) memory=0.80 (0.76);
verbal learning and
memory=1.19 (2.07);
visual learning mem-
ory=0.75 (1.22); reason-
ing and problem solv-
ing=1.76 (2.05)

hypothesis, the number of hours programs devoted to
cognitive remediation was not related to the amount of
improvement in overall cognitive functioning. However,
hours of training, as well as use of drill and practice rather
than combined drill and practice with strategy coaching,
were related to improvements in verbal learning and
memory, suggesting that this domain may be more sensi-
tive to the method and extent of cognitive remediation.
It is possible that a relatively limited amount of cogni-
tive remediation (e.g., 5–15 hours) is sufficient to produce
improved cognitive functioning and that all studies pro-
vided an adequate amount of treatment. Alternatively, the
amount of cognitive remediation may not be related to
immediate gains in cognitive functioning but could con-
tribute to the retention of improvements following the ter-
mination of treatment. The impact of amount of cognitive
remediation on the maintenance of treatment effects
could not be evaluated in this meta-analysis because only
six studies conducted follow-up assessments an average
of 8 months after completion of the program. However,
the mean effect size for overall cognitive performance for
these studies was in the medium range (0.66), comparable
in magnitude to the immediate effects of cognitive reme-
diation. These findings provide preliminary support for
the longer-term benefits of cognitive remediation on cog-
nitive performance and point to the need for more re-
search on the maintenance of treatment effects.
The overall effect size of cognitive remediation on im-
proving symptoms was significant but in the small range
(0.28). Previous reviews of the effects of cognitive remedi-
ation either have not examined symptoms (10, 11) or were
inconclusive because of the small number of studies (12,
13). The apparently limited impact of cognitive remedia-
tion on symptoms is consistent with numerous studies
showing that cognitive impairment is relatively indepen-
dent of other symptoms of schizophrenia (31–33). Cogni-
tive remediation may have some beneficial effects on
symptoms by providing positive learning experiences that
serve to bolster self-esteem and self-efficacy for achieving
personal goals, thereby improving depression. Several
studies have reported that cognitive remediation im-
proved mood (24, 27, 34).
Cognitive remediation also had a significant effect on
improving psychosocial functioning, with an average ef-
fect size of 0.35, just slightly lower than the average effect
size of 0.41 for improved cognitive performance. For ex-
ample, patients who participated in cognitive remediation
showed greater improvements in obtaining and working
competitive jobs (24, 25), the quality of and satisfaction
with interpersonal relationships (19), and the ability to
solve interpersonal problems (20). These findings are
unique because until recently a sufficient number of stud-
ies had not measured functional outcomes from which to
draw firm conclusions. The impact of cognitive remedia-
tion on improved functioning is important because the
primary rationale for cognitive remediation in schizo-
phrenia is to improve psychosocial functioning (35).
In contrast to the uniform effects across studies of cog-
nitive remediation on overall cognitive performance and
symptoms, there was significant variability in its effects on
psychosocial functioning. Furthermore, as hypothesized,
cognitive remediation programs that provided adjunctive
psychiatric rehabilitation had significantly stronger ef-
fects on improving functional outcomes (0.47) than pro-
grams that did not (0.05). This effect is consistent with pre-
vious research showing that cognitive impairment
attenuates response to psychiatric rehabilitation (1, 36,
37) and suggests that improved cognitive performance
may enable some patients to benefit more from rehabilita-
tion. The findings are also consistent with the results of a
meta-analysis of integrated psychological therapy (38) in
which the strongest effects on functioning were found in
programs that integrated cognitive remediation and social
skills training rather than programs that provided either
intervention alone (39).
Cognitive remediation programs that included strategy
coaching had stronger effects on functioning than pro-
grams that focused only on drill and practice. Strategy
coaching typically targets memory and executive func-
tions by teaching methods such as chunking information
to facilitate recall and problem-solving skills. It is unclear
whether strategy coaching is more effective because peo-
ple are better able to transfer skills from the training set-
ting into their daily lives (35) or because teaching such
strategies helps patients compensate for the effects of per-

Am J Psychiatry 164:12, December 2007 ajp.psychiatryonline.org 1799

COGNITIVE REMEDIATION IN SCHIZOPHRENIA

TABLE 3. Results of Meta-Analysis of Randomized, Controlled Trials of Cognitive Remediation in Schizophreniaa

Cognitive
Subjects Remediation Hours Analysis
Outcome Domain Effect Size 95% CI T Score (N) Median Range Hedges’s Q df
Global cognition 0.41 0.29 to 0.52 6.9*** 1,214 12.5 3–75 35.3 28
Attention/vigilance 0.41 0.25 to 0.57 5.1*** 659 6.6 0–14 9.8 14
Speed of processing 0.48 0.28 to 0.69 5.9*** 655 0.0 0–3 20.7 13
Verbal working memory 0.52 0.33 to 0.72 5.2*** 428 0.4 0–8 3.9 10
Verbal learning and memory 0.39 0.20 to 0.58 5.5*** 858 0.0 0–8 26.6* 15
Visual learning and memory 0.09 –0.26 to 0.43 0.6 424 0.0 0–3 14.5* 7
Reasoning/problem solving 0.47 0.30 to 0.64 5.4*** 564 3.0 0–32 21.8 14
Social cognition 0.54 0.22 to 0.88 3.9*** 228 26.0 2–84 2.8 2
Symptoms 0.28 0.13 to 0.43 3.6*** 709 12.2 14
Functioning 0.35 0.07 to 0.62 1.9* 615 25.7** 10
aAfter consideration of the consistency of effect sizes across six of the seven cognitive domains and overall cognitive functioning, the clinical
and theoretical significance of these moderator effects on verbal learning and memory is unclear.
*p<0.05. ** p<0.01. ***p<0.001.

FIGURE 1. Effect Sizes for Overall Cognition in Random- sistent cognitive impairments on functioning (24) or both.
ized, Controlled Trials of Cognitive Remediation in Schizo- Further research is needed to address this question.
phrenia
The effects of cognitive remediation were not influ-
Benedict & Harris (46), treatment as usual enced by the nature of the control condition. Thus, simply
Benedict & Harris (46), active control actively or passively engaging patients in treatments de-
Wagner (45), treatment 1
signed to control for the amount of clinician contact did
not appear to confer any benefit in cognitive functioning
Meichenbaum & Cameron (16)
beyond the provision of usual services. These findings are
Penadés et al. (29)
consistent with the meta-analysis of the cognitive remedi-
Field et al. (49) ation-based integrated psychological therapy program
Sartory et al. (56) (39) but differ from the psychotherapy literature, where
Hogarty et al. (19) there is ample evidence for nonspecific effects related to
Vauth et al. (25), active control therapist attention (40). The mechanisms underlying the
Vauth et al. (25), treatment as usual
effects of cognitive remediation on improved cognitive
performance, functioning, and symptoms appear to differ
López-Luengo & Vázquez (55)
from those involved in psychotherapy. The results raise
Bellucci et al. (34)
questions about the need to control for the amount of cli-
Burda et al. (48) nician attention given to treatment control groups in re-
Bell et al. (26, 52); Fiszdon et al. (53, 54) search on cognitive remediation.
Olbrich & Mussgay (43) So what has been learned after almost 40 years of re-
Silverstein et al. (22) search on cognitive remediation for schizophrenia? Al-
Ueland & Rund (44) though a great deal more is known about schizophrenia
McGurk et al. (24) and its neurocognitive underpinnings and the technology
for assessing and remediating cognitive impairments has
Wagner (45), treatment 3
evolved (e.g., most programs now employ at least some
Benedict et al. (47)
computer-based training), the effect sizes on cognitive
van der Gaag et al. (23) functioning do not appear to have increased appreciably
Wykes et al. (27) in recent years. The failure to develop more potent pro-
Medalia et al. (50) grams could be due to limitations imposed by the illness
Hermanutz & Gestrich (42), active control itself and not the fault of treatment developers. It may be
Spaulding et al. (20) argued that a similar phenomenon has occurred in the
pharmacological treatment of schizophrenia, where de-
Wagner (45), treatment 2
spite the enormous investment of resources into the de-
Hermanutz & Gestrich (42),
treatment as usual velopment of new drugs, the clinical gains in treating
Medalia et al. (51), treatment 2 symptoms over the past 50 years are debatable (41).
Medalia et al. (51), treatment 1 Alternatively, the ability to improve the effectiveness of
cognitive remediation may depend on attention to critical
–2.0 –1.0 0.0 1.0 2.0 3.0
issues in research design. Two such issues deserve special
Effect Size
consideration: the evaluation of the persistence of reme-

1800 ajp.psychiatryonline.org Am J Psychiatry 164:12, December 2007


diation effects on cognitive functioning and the assess-
ment of the impact of remediation on functional out-
comes. Despite the number of controlled studies of
cognitive remediation, only six studies (16, 19, 21, 28–30)
examined whether improvements in cognitive function-
ing were maintained at a posttreatment follow-up, pre-
cluding the exploration of moderators of treatment ef-
fects. The relative lack of data addressing this question
may be important because different program, patient, or
setting factors could influence the long-term mainte-
nance of cognitive effects compared to short-term effects.
Similarly, only 11 studies evaluated functional out-
comes (16, 19, 20, 22, 24, 25, 27, 29, 42–44), and this was
the first meta-analysis to quantitatively demonstrate that
cognitive remediation improved psychosocial function-
ing. Furthermore, the impact of cognitive remediation on
functioning was moderated by several factors, including
the provision of adjunctive psychiatric rehabilitation, cog-
nitive training method, and patient age, suggesting poten-
tially important factors for improving the impact of treat-
ment programs. Thus, the ability to make cognitive
remediation programs more effective may have been con-
strained by the neglect of most studies to measure the
long-term effects of remediation and its impact on func-
tional outcomes, resulting in the inability to identify mod-
erators of treatment that could be the focus of efforts to
hone and refine the intervention. Future research on cog-
nitive remediation should routinely evaluate psychosocial
functioning and the long-term effects of treatment on all
outcomes of interest. In addition, research that systemati-
cally examines the interactions between cognitive remedi-
ation and psychiatric rehabilitation is warranted.
In summary, cognitive remediation was found to have
consistent effects on improving cognitive performance,
functioning, and symptoms. In addition, the impact of
cognitive remediation on functional outcomes was signif-
icantly greater in studies that also provided psychiatric re-
habilitation, suggesting that these two treatment ap-
proaches may work together in a synergistic fashion.
These findings challenge the assumption that simply im-
proving cognitive functioning in schizophrenia will spon-
taneously lead to better psychosocial outcomes. The re-
sults do suggest, however, that cognitive remediation may
improve the response of some patients to psychiatric re-
habilitation. Overall, this meta-analysis indicates that cog-
nitive remediation may have an important role to play in
improving both cognitive performance and functional
outcomes in schizophrenia.
Received June 8, 2007; revision received Aug. 27, 2007; accepted
Aug. 28, 2007 (doi: 10.1176/appi.ajp.2007.07060906). From the
Dartmouth Psychiatric Research Center, the Department of Commu-
nity and Family Medicine, and the Department of Psychiatry, Dart-
mouth Medical School; the Department of Psychiatry, University of
California, San Diego; and the School of Psychology, Argosy Univer-
sity, Santa Monica, Calif. Address correspondence and reprint
requests to Dr. McGurk, Dartmouth Psychiatric Research Center, Main
Am J Psychiatry 164:12, December 2007
McGURK, TWAMLEY, SITZER, ET AL.
Building, 105 Pleasant St., Concord, NH 03301; susan.r.mcgurk@
dartmouth.edu (e-mail).
All authors report no competing interests.
Supported by NIMH grant MH77210 and National Institute on Dis-
ability and Rehabilitation Research grant H133G050230.
References
1. McGurk SR, Mueser KT: Cognitive functioning, symptoms, and
work in supported employment: a review and heuristic model.
Schizophr Res 2004; 70:147–174
2. Mueser KT: Cognitive functioning, social adjustment and long-
term outcome in schizophrenia, in Cognition in Schizophrenia:
Impairments, Importance, and Treatment Strategies. Edited by
Sharma T, Harvey P. Oxford, UK, Oxford University Press, 2000,
pp 157–177
3. Corrigan PW, Mueser KT, Bond GR, Drake RE, Solomon P: The
Principles and Practice of Psychiatric Rehabilitation: An Empir-
ical Approach. New York, Guilford, 2007
4. Smith TE, Hull JW, Romanelli S, Fertuck E, Weiss KA: Symptoms
and neurocognition as rate limiters in skills training for psy-
chotic patients. Am J Psychiatry 1999; 156:1817–1818
5. Wykes T, Dunn G: Cognitive deficit and the prediction of reha-
bilitation success in a chronic psychiatric group. Psychol Med
1992; 22:389–398
6. Nuechterlein KH, Barch DM, Gold JM, Goldberg TE, Green MF,
Heaton RK: Identification of separable cognitive factors in
schizophrenia. Schizophr Res 2004; 72:29–39
7. Marder SR: Initiatives to promote the discovery of drugs to im-
prove cognitive function in severe mental illness. J Clin Psychi-
atry 2006; 67(suppl 9):31–35
8. Rund BR, Borg NE: Cognitive deficits and cognitive training in
schizophrenic patients: a review. Acta Psychiatr Scand 1999;
100:85–95
9. Harvey PD, Green MF, Keefe RS, Velligan DI: Cognitive function-
ing in schizophrenia: a consensus statement on its role in the
definition and evaluation of effective treatments for the ill-
ness. J Clin Psychiatry 2004; 65:361–372
10. Krabbendam L, Aleman A: Cognitive rehabilitation in schizo-
phrenia: a quantitative analysis of controlled studies. Psycho-
pharmacology 2003; 169:376–382
11. Kurtz MM, Moberg PJ, Gur RC, Gur RE: Approaches to cognitive
remediation of neuropsychological deficits in schizophrenia: a
review and meta-analysis. Neuropsychology Rev 2001; 11:
197–210
12. Pilling S, Bebbington P, Kuipers E, Garety P, Geddes JR, Martin-
dale B, Orbach G, Morgan C: Psychological treatments in
schizophrenia, II: meta-analyses of randomized controlled tri-
als of social skills training and cognitive remediation. Psychol
Med 2002; 32:783–791
13. Twamley EW, Jeste DV, Bellack AS: A review of cognitive train-
ing in schizophrenia. Schizophr Bull 2003; 29:359–382
14. Thalheimer W, Cook S: How to calculate effect sizes from pub-
lished research: a simplified methodology. www.work-learn-
ing.com/effect_sizes.htm
15. Cohen J: Statistical Power Analysis for the Behavioral Sciences.
Hillsdale, NJ, Lawrence Erlbaum Associates, 1988
16. Meichenbaum D, Cameron R: Training schizophrenics to talk to
themselves: a means of developing attentional controls. Behav
Ther 1973; 4:515–534
17. Borenstein M, Rothstein H: Comprehensive Meta-Analysis: A
Computer Program for Research Synthesis. Englewood, NJ, Bio-
stat, 1999
18. Hedges LV, Olkin I: Statistical Methods for Meta-Analysis. New
York, Academic Press, 1985
19. Hogarty GE, Flesher S, Ulrich RF, Carter M, Greenwald D, Pogue-
Geile MF, Kechavan M, Cooley S, Di Barry AL, Garrett A, Pare-
ajp.psychiatryonline.org 1801
COGNITIVE REMEDIATION IN SCHIZOPHRENIA
pally H, Zoretich R: Cognitive enhancement therapy for schizo-
phrenia: effects of a 2-year randomized trial on cognition and
behavior. Arch Gen Psychiatry 2004; 61:866–876
20. Spaulding WD, Reed D, Sullivan M, Richardson C, Weiler M: Ef-
fects of cognitive treatment in psychiatric rehabilitation.
Schizophr Bull 1999; 25:657–676
21. Ueland T, Rund BR: Cognitive remediation for adolescents with
early onset psychosis: a 1-year follow-up study. Acta Psychiatr
Scand 2005; 111:193–201
22. Silverstein SM, Hatashita-Wong M, Solak BA, Uhlhaas P, Landa
Y, Wilkniss SM, Goicochea C, Carpiniello K, Schenkel LS, Savitz A,
Smith TE: Effectiveness of a two-phase cognitive rehabilitation
intervention for severely impaired schizophrenia patients. Psy-
chol Med 2005; 35:829–837
23. van der Gaag M, Kern RS, van den Bosch RJ, Liberman RP: A
controlled trial of cognitive remediation in schizophrenia.
Schizophr Bull 2002; 28:167–176
24. McGurk SR, Mueser KT, Pascaris A: Cognitive training and sup-
ported employment for persons with severe mental illness:
one year results from a randomized controlled trial. Schizophr
Bull 2005; 31:898–909
25. Vauth R, Corrigan PW, Clauss M, Dietl M, Dreher-Rudolph M,
Stieglitz R-D, Vater R: Cognitive strategies versus self-manage-
ment skills as adjunct to vocational rehabilitation. Schizophr
Bull 2005; 31:55–66
26. Bell MD, Bryson G, Greig T, Corcoran C, Wexler RE: Neurocogni-
tive enhancement therapy with work therapy. Arch Gen Psychi-
atry 2001; 58:763–768
27. Wykes T, Reeder C, Corner J, Williams C, Everitt B: The effects of
neurocognitive remediation on executive processing in pa-
tients with schizophrenia. Schizophr Bull 1999; 25:291–307
28. Fiszdon JM, Whelahan H, Bryson GJ, Wexler BE, Bell MD: Cogni-
tive training of verbal memory using a dichotic listening para-
digm: impact on symptoms and cognition. Acta Psychiatr
Scand 2005; 112:187–193
29. Penadés R, Catalán R, Salamero M, Boget T, Puig O, Guarch J,
Gastó C: Cognitive remediation therapy for outpatients with
chronic schizophrenia: a controlled and randomized study.
Schizophr Res 2006; 87:323–331
30. Wykes T, Reeder C, Williams C, Corner J, Rice C, Everitt B: Are
the effects of cognitive remediation therapy (CTR) durable? re-
sults from an exploratory trial in schizophrenia. Schizophr Res
2003; 61:163–174
31. Harvey PD, Serper MR, White L, Parrella M, McGurk SR, Moriarty
PJ, Bowie C, Vadhan N, Friedman J, Davis KL: The convergence
of neuropsychological testing and clinical ratings of cognitive
impairment in patients with schizophrenia. Compr Psychiatry
2001; 42:306–313
32. Liddle PF: The symptoms of chronic schizophrenia: a re-exam-
ination of the positive-negative dichotomy. Br J Psychiatry
1987; 151:145–151
33. Mueser KT, Curran PJ, McHugo GJ: Factor structure of the Brief
Psychiatric Rating Scale in schizophrenia. Psychol Assessment
1997; 9:196–204
34. Bellucci DM, Glaberman K, Haslam N: Computer-assisted cog-
nitive rehabilitation reduces negative symptoms in the se-
verely mentally ill. Schizophr Res 2002; 59:225–232
35. Wykes T, Reeder C: Cognitive Remediation Therapy for Schizo-
phrenia: Theory and Practice. London, Routledge, 2005
36. Mueser KT, Bellack AS, Douglas MS, Wade JH: Prediction of so-
cial skill acquisition in schizophrenic and major affective disor-
der patients from memory and symptomatology. Psychiatry
Res 1991; 37:281–296
37. Wykes T, Sturt E, Katz R: The prediction of rehabilitative success
after three years—the use of social, symptom and cognitive
variables. Br J Psychiatry 1990; 157:865–870
1802 ajp.psychiatryonline.org
38. Brenner H, Roder V, Hodel B, Kienzle N, Reed D, Liberman R:
Integrated Psychological Therapy for Schizophrenic Patients.
Seattle, Hogrefe & Huber, 1994
39. Roder V, Mueller DR, Mueser KT, Brenner HD: Integrated psy-
chological therapy (IPT) for schizophrenia: is it effective?
Schizophr Bull 2006; 32(suppl 1):S81–S93
40. Crits-Christoph P, Baranackie K, Kurcias JS, Beck AT, Carroll K,
Perry K, Luborsky L, McLellan AT, Woody GE, Thompson L, Gal-
lagher D, Zitrin C: Meta-analysis of therapist effects in psycho-
therapy outcome studies. Psychotherapy Res 1991; 1:81–91
41. Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA,
Perkins DO, Keefe RS, Davis SM, Davis CE, Lebowitz BD, Severe
J, Hsiao JK: Clinical Antipsychotic Trials of Intervention Effec-
tiveness (CATIE) investigators: effectiveness of antipsychotic
drugs in patients with chronic schizophrenia. N Engl J Med
2005; 353:1209–1223
42. Hermanutz M, Gestrich J: Computer-assisted attention training
in schizophrenics: a comparative study. Eur Arch Psychiatry
Clin Neurosci 1991; 240:282–287
43. Olbrich R, Mussgay L: Reduction of schizophrenic deficits by
cognitive training: an evaluation study. Eur Arch Psychiatry
Neurol Sci 1990; 239:366–369
44. Ueland T, Rund BR: A controlled randomized treatment study:
the effects of a cognitive remediation program on adolescents
with early onset psychosis. Acta Psychiatr Scand 2004; 109:70–
74
45. Wagner BR: The training of attending and abstracting re-
sponses in chronic schizophrenics. J Exper Res Personality
1968; 3:77–88
46. Benedict RHB, Harris AE: Remediation of attention deficits in
chronic schizophrenic patients: a preliminary study. Br J Clin
Psychol 1989; 28:187–188
47. Benedict RHB, Harris AE, Markow T, McCormick JA, Nuechter-
lein KH, Asarnow RF: Effects of attention training on informa-
tion processing in schizophrenia. Schizophr Bull 1994; 20:537–
546
48. Burda PC, Starkey TW, Dominguez F, Vera V: Computer-assisted
cognitive rehabilitation of chronic psychiatric inpatients. Com-
puters Hum Behav 1994; 10:359–368
49. Field CD, Galletly C, Anderson D, Walker P: Computer-aided
cognitive rehabilitation: possible application to the attentional
deficit of schizophrenia: a report of negative results. Percept
Mot Skills 1997; 85:995–1002
50. Medalia A, Aluma M, Tryon W, Merriam AE: Effectiveness of at-
tention training in schizophrenia. Schizophr Bull 1998; 24:
147–152
51. Medalia A, Dorn H, Watras-Gans S: Treating problem solving
deficits on an acute psychiatric inpatient unit. Psychiatry Res
2000; 97:79–88
52. Bell M, Bryson G, Wexler BE: Cognitive remediation of working
memory deficits: durability of training effects in severely im-
paired and less severely impaired schizophrenia. Acta Psychi-
atr Scand 2003; 108:101–109
53. Fiszdon JM, Bryson GJ, Wexler BE, Bell MD: Durability of cogni-
tive remediation training in schizophrenia: performance on
two memory tasks at 6-month and 12-month follow-up. Psy-
chiatry Res 2004; 125:1–7
54. Fiszdon JM, Cardenas AS, Bryson GJ, Bell MD: Predictors of re-
mediation success on a trained memory task. J Nerv Ment Dis
2005; 193:602–608
55. López-Luengo B, Vázquez C: Effects of attention process train-
ing on cognitive functioning of schizophrenic patients. Psychi-
atry Res 2003; 119:41–53
56. Sartory G, Zorn C, Groetzinger G, Windgassen K: Computerized
cognitive rehabilitation improves verbal learning and process-
ing speed in schizophrenia. Schizophr Res 2005; 75:219–223
Am J Psychiatry 164:12, December 2007